Healthcare Provider Details

I. General information

NPI: 1184816092
Provider Name (Legal Business Name): DAVID M. SHEPHERD MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2007
Last Update Date: 05/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41935 W 12 MILE RD SUITE 103
NOVI MI
48377-3111
US

IV. Provider business mailing address

41935 W 12 MILE RD SUITE 103
NOVI MI
48377-3111
US

V. Phone/Fax

Practice location:
  • Phone: 248-347-8030
  • Fax: 248-305-6694
Mailing address:
  • Phone: 248-347-8030
  • Fax: 248-305-6694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number32402
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number32402
License Number StateMI

VIII. Authorized Official

Name: DR. DAVID MARTIN SHEPHERD
Title or Position: PRESIDENT
Credential: MD
Phone: 248-347-8030